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Fire Safety Policy
Approved By: Policy and Guideline Committee
Date of Original 4 July 2002 – Trust Board
Approval:
Trust Reference: A7/2002
Version: 20 October 2017
Supersedes: July 2014
Trust Lead: Michael Blair – QSHE Lead
Board Director
Darryn Kerr
Lead:
Date of Latest 20 October 2017 – Policy and Guideline Committee
Approval
Next Review Date: October 2020CONTENTS
Section Page
1 Introduction and Overview 3
2 Policy Scope 4
3 Definitions and Abbreviations 4
4 Roles and Responsibilites 5
5 Policy Implementation and Associated Documents 13
6 Education and Training 13
7 Process for Monitoring Compliance 14
8 Equality Impact Assessment 16
9 Supporting References, Evidence Base and Related Policies 16
10 Process for Version Control, Document Archiving and Review 17
Appendices Page
A UHL Fire Safety Structure 18
B Fire Safety Training Needs Analysis 19
C Fire Evacuation Procedure 20
D Personal Emergency Evacuation Plan (PEEP) Assessment 22
E Personal Emergency Evacuation Plan (PEEP) 24
F Fire / Unwanted Fire Signal Report 26
G Switchboard Fire Signal Notification 30
H Project Notification 31
REVIEW DATES AND DETAILS OF CHANGES MADE DURING THE REVIEW
Complete review and re-write
KEY WORDS
Fire
Fire Risk Assessment
Fire Safety Training
Fire Evacuation Procedure
PEEP
Fire Warden
Fire Safety Policy Page 2 of 32
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NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guideline library on INsite1 INTRODUCTION AND OVERVIEW
1.1 Operational Fire Safety is reliant on both physical fire precautions and effective
management. This policy provides guidance in respect of the management of fire
safety within the University Hospitals of Leicester (UHL) NHS Trust.
1.2 The Trust recognises that the effective implementation of its Fire Management
Policies, Procedures and guidance depends on managers, staff and other
representatives working together at all levels to ensure safe working practices
are identified and implemented. In so doing the Trust complies with its statutory
requirements in respect of fire safety management.
1.4 It ensures that suitable and sufficient governance protocols are in place to
manage fire-related matters and demonstrates due diligence to minimise the
incidence of fire throughout all activities provided by, or on behalf of, University
Hospitals of Leicester NHS Trust.
1.5 Where fire does occur, this policy aims to minimise the impact of such
occurrence on life safety, the delivery of patient care, the environment and
property.
1.6 The healthcare environment offers unique challenges due to the wide ranging
nature of the building types, their complexity and the diverse range of users and
occupiers.
1.7 The Regulatory Reform (Fire Safety) Order 2005 (RRFSO) requires a managed
risk approach to fire safety. The process of fire risk assessment, mitigation and
review requires a robust system of management capable of identifying hazards,
qualifying their impact, devising appropriate mitigation and continual monitoring.
1.8 In order to meet these requirements and to manage Fire Safety, the Trust will
ensure measures are in place as set out below:
a) Having a clearly defined fire safety policy covering all buildings
occupied by the Trust;
b) Outlining key roles and responsibilities that reflect the organisation
and size of the Trust;
c) Nominating a board level director accountable to the Chief
Executive for Fire Safety;
d) Nominating a Fire Safety Manager to take a lead on all fire safety
activities;
e) Establishing and implementing effective Fire Safety Protocols;
f) Develop partnership initiatives with other local healthcare trusts,
safety agencies and bodies in the provision of fire safety, as well as
through fire safety awareness campaigns.
Fire Safety Policy Page 3 of 32
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2.1 This policy applies wherever University Hospitals of Leicester NHS Trust owes a
duty of care to patients and other service users, staff or other individuals.
2.2 This policy is applicable to all staff employed by the Trust, either directly or
indirectly, and to any other person or organisation which uses Trust services or
premises for any purpose.
2.3 It will also apply to bank, temporary staff, volunteers, young workers and
contractors working on Trust business.
2.4 It details a clearly defined management structure for the delivery, control and
monitoring of fire safety measures, enabling it to be shared across the
organisation. See Appendix A.
2.5 Independent or third party contractors in Trust owned, controlled or occupied
premises, although not specifically covered by this policy, shall have in place
suitable fire safety arrangments to demonstrate how they satisfy the duties
placed upon them by the Regulatory Reform (Fire Safety) Order 2005.
2.6 Under article 22 of the RRFSO there is an explicit duty to ensure that all
reasonable steps are taken to co-operate and to co-ordinate fire safety measures
where two or more responsible persons share, or have duties in respect of,
premises (whether on a temporary or a permanent basis) to comply with the
requirements and prohibitions imposed on them by or under the Order
2.6 Fire Safety Training is required for all staff employed by UHL and forms part of
the Mandatory training needs of the Trust. Different levels are offered and
required by job type / clinical setting as set out in Appendix B.
3 DEFINITIONS AND ABBREVIATIONS
Competence: Where a person is required to be competent they must be able to
demonstrate through training and experience or knowledge and other qualities that they
have the ability to properly asset in undertaking the preventative and protective
measures
Competent Person (Fire): A person who can provide skilled installation and/or
maintenance of fire-related services (both passive and active fire safety systems)
Fire Risk Assessment: The process of identifying fire hazards and evaluating the risks
to people, property, assets and the environment arising from them, taking into account
the adequacy of existing fire precautions, and deciding whether the risk is acceptable
without the addition of further controls (fire precautions).
Responsible Person: The employer of persons working at the premises, a person who
has control of the premises, or the owner of the premises
BS British Standard
CLG Communities and Local Government
HTM Healthcare Technical Memorandum
LFRS Leicester Fire and Rescue Service
RRFSO Regulatory Reform (Fire Safety) Order 2005
UwFS Unwanted Fire Signal
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4.1 The Trust has identified specific responsibilities to be discharged at various
levels throughout the organisation's management structure to facilitate
compliance with the RRFSO and Healthcare Technical Memorandum (HTM) 05
Series (often referred to as the Fire Code). The Trust Fire Safety structure is
illustrated in Appendix A.
4.2 Trust Board
4.2.1 Overall responsibility for Fire Safety will rest with the Trust Board. The Trust
Board have overall accountability for the activities of the organisation. The Trust
Board should ensure that it receives appropriate assurance of compliance with
Trust policy, legislation, codes of practice and guidance documents.
4.3 Trust Chief Executive
4.3.1 The Chief Executive is nominated the “Responsible Person” for the Trust as
defined in the RRFSO.
4.3.2 The Chief Executive has overall responsibility for ensuring, through suitable
delegation, that suitable and sufficient arrangements, policies and work
programmes are implemented to comply with current Fire Legislation, guidance
and best practice in all premises owned or occupied by the Trust.
4.3.3 They also are responsible for the appointment of an Executive Director
responsible for Fire Safety Management.
4.4 Nominated Executive Director Responsible for Fire
4.4.1 The Director of Estates and Facilities is responsible for championing Fire Safety
Issues at Board level and represents the Trust Chief Executive.
4.4.2 Main duties include, but are not limited to:
a) Appoint a Fire Safety Manager and other ‘Competent Persons’ to assist
them in undertaking the measures needed to comply with the
requirements and prohibitions of the RRFSO;
b) Establish corporate fire safety arrangements for planning, organising,
controlling and review of measures required by the RRFSO;
c) Report to the Trust Board on the fire safety arrangements in Trust
premises, including record keeping, fire safety training and evacuation
exercises;
d) Develop an on-going programme of Capital Work within the Trust
Business Plan for the improvement of fire precautions;
e) Present the Annual Fire Safety Report to the Board.
4.5 Head of Estates Transformation and Property / Regional Estates Managers
4.5.1 The Head of Estates and Property via the Regional Estates Managers will be
responsible for the maintenance of the active and passive fire protection systems in
Trust premises.
Fire Safety Policy Page 5 of 32
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organisation that will provide skilled installation and for maintenance of fire related
services (both passive and active systems).
4.5.3 The main duties in respect of fire safety are:
a) Charing the UHL Fire Safety Group (Committee);
b) Maintain all structural fire protection arrangements;
c) Maintain fire alarm and detection systems, fire extinguishers, fire doors,
emergency lighting systems, fire compartments, fire dampers, air sampling
units, ventilation systems, suppression systems, including the retention of
appropriate records, and the appointment and management of the
‘Competent Person’;
d) Maintain all risers, hydrants and access routes for the Fire Service;
e) Ensure that all work undertaken on behalf of the Trust is fully compliant with
current legislation and guidance e.g. fire alarm systems, primary and
emergency lighting, fire fighting equipment, asbestos, fire compartmentation,
fixed electrical wiring, portable appliance testing, inspection and maintenance
of external stairs and all passive fire protection within all buildings;
f) Provide and maintain accurate fire plans;
g) Liaise with those responsible for carrying out any maintenance, redecoration,
and structural alterations;
h) Consult with the Trust Fire Safety Team on all new projects and
refurbishments;
i) Assist in the development of an on-going programme of work for the periodic
maintenance and improvement of fire precautions.
4.6 Fire Safety Manager
4.6.1 The role of Fire Safety Manager, within the meaning set out in Health Technical
Memorandum 05-01: Managing healthcare fire safety, will be undertaken by the
Head of Quality, Safety, Health and Environment (QSHE) Compliance.
4.6.2 The Fire Safety Manager will be accountable to the Head of Estates
Transformation and Property responsible for Fire via the Director of Estates and
Facilities.
4.6.3 Additionally they are accountable for ensuring that the framework for fire safety
within the Trust is in place and maintained.
4.6.4 The Fire Safety Manager must ensure that management arrangements are
sufficiently robust and extensive to cover all fire safety issues.
4.6.5 The main duties and responsibilities of the Fire Safety Manager are to:
a) Co-ordinate the development of a fire safety management system that
complies with the requirements of the RRFSO, provides an assurance
framework, and provides a means for the continual improvement of fire
safety management within the Trust;
b) Maintain and report on corporate fire safety arrangements for planning,
organising, controlling and review of measures required by the RRFSO
and Firecode;
c) Co-ordinate the development and implementation of the Trust Fire Safety
Strategy;
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Policy;
e) Co-ordinate the provision of appropriate fire safety advice;
f) Co-ordinate the development of the fire safety training curriculum and
prepare regular reports on the provision of training;
g) Co-ordinate the programme of fire risk assessments of Trust premises,
and the management of the fire safety risk register;
h) Monitor and report on the local fire safety arrangements in all premises
occupied by the Trust (procedures, training, evacuation exercises, records
maintenance, etc.);
i) Assist in the development of an on-going programme of work within the
Trust Business Plan for the periodic maintenance and improvement of fire
precautions;
j) Provide appropriate fire safety advice for projects undertaken as part of
the Trusts Capital Investment Programme;
k) Undertake a regular review of fire safety; prepare an annual report
regarding the management of fire safety and co-ordinate the preparation
of the annual fire safety action plan.
4.6.6 The Fire Manager may seek the advice / services of an Authorising Fire
Engineer, as necessary, in considering a scientific and engineered approach to
the fire safety strategy.
4.7 Fire Safety Advisors
4.7.1 The Trust directly employ full time Fire Safety Advisors that are responsible for
providing technical expertise on Fire Safety to the Fire Safety Manager in the
interpretation and application of relevant Statutory Provisions, Department of
Health Technical Memorandum (HTM) and other guidance in respect of Fire
Safety in Trust premises.
4.7.2 They are also required to monitor and report on the current state of fire
precautions within the Trust’s portfolio.
4.7.3 The duties of the Fire Safety Advisors include:
a) Provision of advice to the Heads of Clinical Service Units,
Department/Ward Managers and Deputies regarding duties under fire
safety legislation and guidance;
b) The undertaking of fire risk assessments for all Trust premises;
c) Audit fire safety records and undertake Fire Safety Audits;
d) Advise on the fire requirements of any development works that have an
effect on the fire integrity of the Trusts buildings;
e) To assist managers in planning of evacuation drills, and monitoring their
effectiveness;
f) Investigate & report on fire incidents;
g) Auditing the maintenance of all first aid fire fighting equipment, fire safety
signs, notices, fire alarm systems, etc.;
h) Delivery of staff fire safety training;
i) Assisting and advising management on the interpretation and
implementation of Firecode and other legislation;
j) Liaising with Trust staff, local building control officers and the fire
authorities in the specifying of fire precautions to new and existing
premises;
k) Assist staff in the improvement of patient awareness of fire safety;
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necessary;
m) Monitor local fire safety arrangements to ensure that local fire risk
assessments, fire procedures are in place and current;
4.8 Heads of Clinical Management Groups (CMGs) and Corporate Directorates
4.8.1 The ethos of the RRFSO is for prevention and mitigation where actually
preventing fires and mitigating their effects when they happen are as important
as means of escape and allied traditional fire precautions. This has placed
additional emphasis on the Trust to develop its fire safety management systems
especially at a Clinical and Corporate level.
4.8.2 The Heads of the CMGs and the Corporate Directorates have overall
responsibility for Fire Safety Management, fire precautions and fire prevention
within their respective service areas and are to ensure fire safety arrangements
for planning, organising, controlling and review of measures required by fire
legislation are suitable and sufficient.
4.8.3 Constant liaison and support must be given to the Department / Ward Managers
and Deputies who as the departmental ‘Responsible Person’, will implement and
manage all aspects of fire safety at a localised level.
4.9 Senior Managers – Including Heads of Service, Heads of Operations,
General Managers, Service Managers, Department / Ward Managers and
nominated Deputies
4.9.1 The Senior Management team have a fundamental role in the management of
local Fire Safety in the areas under their control. It is a requirement of the
RRFSO to have suitably trained Competent Persons available in case of fire for
each building, ward, unit, department, during the hours that the premises are
occupied. At a local level these key competent persons are the designated Fire
Wardens and their Deputies.
4.9.2 The main fire safety duties of Senior Managers are to:
a) Organise and document local fire safety arrangements, fire precautions and
fire prevention for the areas under their control; See appendix C
b) Monitor fire safety precautions within the workplace and initiate actions to
correct any shortfalls;
c) Appoint a suitable number of ‘Competent Persons’ (Fire Wardens) to assist in
undertaking the measures needed to comply with the requirements and of the
RRFSO;
d) Ensure arrangements are in place to deliver and record local fire safety
training to all, but especially new, members of staff, including agency and
temporary workers. This training should include local fire procedure, locations
and use of alarm call points, extinguishers and emergency escape routes;
e) All departments must complete a minimum of one fire evacuation exercise
annually, monitor performance, and maintain appropriate records. However,
for clinical reasons, a table top evacuation exercise may be considered more
suitable and less disruptive, particularly in inpatient areas. The decision to run
either must be clinical led to limit impact on patients.
f) Ensure that fire safety incidents are reported by the designated persons as
per the incident reporting procedure;
Fire Safety Policy Page 8 of 32
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safety matters including local fire procedures, training, and the outcomes of
risk assessments;
h) Monitor and manage local security arrangements that conflict with normal fire
safety arrangements (i.e. locked fire exit doors, lack of self-closers on
bedroom doors, management of fire alarm call point keys by staff);
i) Maintain a local record of the inspection and testing of fire safety equipment,
and arrange for any defects identified to be reported to the Estates
Department (contained in Ward / Departemtn Fire Log Book);
j) Ensure a procedure is in place to monitor and control ignition sources;
k) Ensure a procedure is in place to monitor and control combustible waste;
l) Minimise the occurrence of false alarms and unwanted fire signals;
m) Ensure a sufficient number of Fire Wardens are trained;
n) Ensure that adequate numbers of staff will always be available and to devise
suitable arrangements to provide for the safe evacuation of all relevant
persons in accordance with the emergency evacuation plan;
o) Where necessary, ensure a procedure is in place for the issue of essential
keys for exit doors, fire alarm call points, fire extinguisher boxes etc. for all
staff;
p) Where necessary, ensure sufficient staff are competently trained and
operationally available, to utilise any emergency evacuation equipment
provided / located within the Ward / Department;
q) Notify the Estates & Facilities Department of any proposed change of use of
the areas within their control;
r) Prepare and maintain a personal emergency evacuation plan (PEEP) for any
person(s) (patient/staff/visitor/contractor) in their department that have a need
for additional assistance to evacuate in the event of an emergency. This also
includes service users who may be sedated, in seclusion or restrained; See
Appendix C and D.
s) Periodically update and maintain a Building / Ward / Department fire log book
which contains records of the following:-
i. On site Secondary Induction training (to include date, time, names of
persons receiving training);
ii. Basic Fire Awareness training ;
iii. Fire Warden training, including any refresher training;
iv. Fire Warden checks;
v. Fire Evacuation Drills or Table-top exercises (to include date, time,
names of persons, duration & comments);
vi. Evacuation plans of the building / department;
vii. Details of fire alarm activations/fires;
viii. All PEEPS that are issued;
ix. The current Fire Risk Assessment;
x. Current Local Fire Procedures;
xi. Record any defects to any fire safety equipment.
The log book is issued on completion of the Fire Wardens course via the Fire
Safety Team on request.
4.10 Fire Safety Group (Committee)
4.10.1 The Fire Safety Group, chaired by the Head of Estates Transformation and
Property, will monitor the Trust's fire arrangements and will provide quarterly
reports to the Trust Health and Safety Committee in line with Governance
arrangements.
Fire Safety Policy Page 9 of 32
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Fire Committee:
a) Head of Estates Transformation and Property
b) Head of QSHE Compliance (Fire Manager)
c) Fire Safety Advisor(s)
d) Regional Estates Manager(s)
e) Capital Projects representation
f) UHL Health and Safety Services representative(s)
g) Clinical Management Groups representatives
4.10.3 UHL Staff side representation is welcomed and there is an open invitation for
their attendance.
4.10.4 Fire Safety ssues or concerns can also be forwarded to the Fire Safety by all
UHL staff using the global email address:
UHLFireSafety@uhl-tr.nhs.uk
4.10.5 Meetings will be held quarterly.
4.11 Duty Manager
4.11.1 The Hospital Duty Manager will normally fulfil the role of Fire Incident Officer,
unless otherwise agreed. For Clinical or non-clinical departments, the Senior
Person present will assist in bringing about a satisfactory conclusion to any fire
incident.
4.11.2 The Duty Manager must take command of the incident and be responsible for the
overall co-ordination of the emergency situation until the Fire and Rescue
Service arrives, and to act as a focus for liaison purposes thereafter.
4.11.3 The Duty Manager must be a manager who will be aware of the local fire
procedures and has received the appropriate training from the Fire Safety team.
4.11.4 Duties of the Duty Manger fulfilling the Fire Coordinator role:
a) Take control of the incident;
b) Direct the local response;
c) Determine whether evacuation is necessary and commence the evacuation;
d) Liaise with the Fire Wardens and other Fire Response Staff at the Fire
Control Point (most often the fire indicator panel in the reception area;
e) Document the event using the Fire / Unwanted Fire signal report in Appendix
E and ensure that the Fire Safety team receive a copy within 48hrs of the
incident.
4.12 Fire Response Team
4.12.1 On all occasions when the fire alarm is activated additional assistance will be
provided at the scene by the Hospital Fire Response Team. This is made up with
staff from Security, Estates, and Porters.
4.12.2 Duties of the Fire Response Team are: -
a) Responding to all alarm activations and/or bleep to attend;
b) Attending training pertinent to their role;
c) Assist the Duty Manager and Fire Wardens during any evacuation.
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4.13.1 Nominated by the Department / Ward Manager the Fire Wardens are designated
‘Competent Persons’ and provide local assistance in the event of a fire
emergency.
4.13.2 This training is provided in-house by the Trust Fire Safety Team and is available
to book via the Learning and Development platform “HELM”.
4.13.3 It is recommended that suitably trained Fire Wardens are available, in each area
and/or department, all the hours that the premises are occupied to assist in the
prevention and mitigation of fires and fire incidents.
4.13.4 The key responsibilities of Fire Wardens are:
a) To report any defective fire safety issues to their Manager immediately;
b) To support the Heads of Clinical Service Units, Department / Ward Managers
and Deputies in the management of fire safety matters;
c) To assist the Trusts Fire Safety Team in fire safety inspections and risk audit
assessments in the area for which they are responsible via the documented
monthly fire checks;
d) To facilitate fire evacuation exercises at their place of work;
e) To be responsible for the co-ordination and direction of staff actions during a
fire, in accordance with the Action Plan and Local Fire Safety Procedure;
f) To liaise with the Trusts Fire Safety Manager / Fire Safety Advisors, in
relation to all fire matters and ensure such matters are acted upon as
appropriate.
4.14 Switchboard
4.14.1 On all occasions when the fire alarm is activated the switchboard are the vital
communication interface internally between identified key Trust staff members
and externally between the Trust and the Fire Service (LFRS).
4.14.2 They are the collectors and conveyors of key information to ensure that the
required response is efficiently and effectively executed.
4.14.3 Duties of the Switchboard Team include: -
a) Monitoring the automatic fire detection / alarms systems across all 3 sites;
b) Monitoring all “2222” calls received, including those related to fire;
c) Summoning the LFRS on activation of the alarm – placing 999 calls (initial
call);
d) Alerting the Duty Manager and Fire Response teams via the “bleep” system;
e) Requesting full attendance of the LFRS when a Fire is confirmed;
f) Requesting standown if false alarm confirmed by Duty Manager or the person
designated in charge of the ward / department at the time of activation ;
g) Accurately complete the Switchboard Fire Signal Notification form – Appendix
G
h) Logging all Fires and Unwanted Fire Signals with the Fire Safety Advisors
and maintaining accurate and suitable records.
4.15 Head of Capital Projects
4.15.1 The Head of Capital Projects assumes responsibility for all capital projects; they
must ensure that all construction & other relevant works undertaken on behalf of
the Trust comply with fire safety legislation, relevant guidance, the Trust Fire
Safety Strategy, and the requirements of this policy.
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are to:
a) Ensure that work undertaken on behalf of the Trust is fully compliant with
current legislation;
b) Ensure that the Fire Safety Team is notified and consulted for each proposed
project;
c) Ensure that project managers and other construction professionals engaged
to undertake work for the Trust are appropriately trained regarding the fire
safety requirements of the Trust;
d) Prioritise and action identified Fire Risks in the backlog maintenance and
capital investment programme;
e) Develop and maintain a system of records and assurance to demonstrate that
all works under his/her control comply with fire safety legislation and
guidance;
f) Appoint, where necessary, an Authorising Engineer for capital investment
projects.
4.16 Project Managers
4.16.1 Project Managers are responsible for ensuring that all construction & other
relevant works under their management comply with fire safety legislation,
relevant guidance and the requirements of this policy.
4.16.2 The main duties of Project Managers in respect of fire safety legislation and
guidance are to:
a) Ensure that all work under their management is fully compliant;
b) Consult with the Trusts Fire Safety Team on all projects no matter how big or
small; – Appendix H
c) Ensure a method statement is completed before work commences;
d) Ensure hot-work permits are issued before work commences;
e) Ensure that unwanted fire signals / false alarms are minimised and actively
managed;
f) Ensure that contractors’ staff and other construction professionals engaged
are appropriately trained regarding the fire safety requirements of the Trust;
g) Develop and maintain a system of records and assurance to demonstrate that
all works under his/her control comply with fire safety legislation and
guidance;
h) Take account of local fire safety procedures in the planning of works and
ensure that local Fire Wardens are briefed on the scope of works and the
programme for their implementation;
i) Ensure all fire safety signs where necessary are replaced/renewed before any
area is reoccupied;
j) Ensure that the contractors and their staff are provided with such training and
information, as they require while working on site (Local Fire Procedures for
the area where they are working);
k) Ensure that all design certificates, installation certificates, modification
certificates, commissioning certificates & acceptance certificates are
completed for work on fire alarm systems.
4.17 Trust Employees, Contractors, Third Parties Employees and Volunteers
4.17.1 All staff have a duty of care to themselves, patients, visitors and other members
of staff and will ensure that they:
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procedures are not being implemented;
b) Comply with statutory requirements, the fire safety policy, fire strategy & fire
evacuation procedures to prevent fire risks and take appropriate action in the
event of a fire;
c) They are required to attend the appropriate level of training and participate in
fire drills; (see appendix B)
d) Act to prevent fire risks and ensure that they do not knowingly compromise
fire safety through their own actions, or omissions;
e) Minimise the occurrence of false alarms and unwanted fire signals.
4.17.2 Employees of third parties sharing Trust premises and contractors working on
Trust premises (for either short or long periods) have the same duties as Trust
Employees in respect of fire safety management.
5. POLICY IMPLEMENTATION AND ASSOCIATED DOCUMENTS –
5.1 The Trust Board expects those tasked with managing aspects of fire safety to:
a) diligently discharge their fire safety responsibilities as befits their position;
b) have in place a clearly defined management structure for the delivery, control
and monitoring of fire safety measures;
c) have in place a programme for the assessment and review of fire risks;
d) develop and implement appropriate protocols, procedures, action plans and
control measures to mitigate fire risks, comply with relevant legislation and,
where practicable, codes of practice and guidance;
e) develop and disseminate appropriate fire emergency action plans pertinent to
each department/building/area to ensure the safety of occupants, protect the
delivery of service and, as far as reasonably practicable, defend the property
and environment;
f) develop and implement a programme of appropriate fire safety training for all
relevant staff;
g) develop and implement monitoring and reporting mechanisms appropriate to
the management of fire safety.
6 EDUCATION AND TRAINING REQUIREMENTS
6.1 It is a mandatory requirement that all staff employed by the Trust attend a fire
induction course on appointment and on-going annual refresher training.
6.2 An on-site secondary induction must be provided by the ‘Responsible
Manager’/Fire Warden within the workplace immediately upon commencement,
outlining all local fire procedures.
6.3 It is the responsibility of the Heads of Clinical Service Units, Department/Ward
Managers and Deputies to ensure that they and their staff comply, and that a
record of attendance is maintained.
6.4 Managers must also ensure, where necessary, that personnel receive enhanced
fire safety training in accordance with the training needs analysis as outlined in
Appendix B
6.5 Managers will ensure that each building, ward, unit or department will undertake
at least one emergency evacuation exercise per year. The exercises will be
recorded indicating date, time, numbers of people, any concerns or remedial
actions necessary.
Fire Safety Policy Page 13 of 32
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NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guideline library on INsite6.6 Managers will ensure that each building, ward, unit or department have a
sufficient number of trained and competent Fire Wardens (and Deputies) to
support an effective evacuation strategy during the hours the premises is
occupied.
6.7 It is recommended that Fire Wardens refresh their training every 3 years.
7 PROCESS FOR MONITORING COMPLIANCE
7.1 The Executive Director responsible for Fire Safety has responsibility for the
overall monitoring of the policy.
7.2 Local monitoring will be through the identified Responsible Person(s) and/or
Competent Persons (Fire Wardens)
a) Periodic review of the Fire Risk Assessment Significant findings
b) Review of local fire Log Book(s)
c) Regular documented Fire Warden checks
7.3 Fire Safety Manager and Trust Fire Safety Advisors through:
a) Periodic review of fire and false alarm incident reports;
b) Periodic review of fire safety training records;
c) Periodic review of fire service notices and communications;
d) Periodic Fire safety assurance audits;
e) Periodic third-party fire safety audit (as deemed appropriate).
7.3 Staff awareness of the Trusts Fire Safety Policy & Strategy document is
monitored through fire risk assessments, fire evacuation drills and mandatory fire
training;
7.4 Quarterly and Annual reports submitted to the UHL Health and Safety
Committee;
7.5 Annual Fire Compliance declaration signed by the Chief Executive, the Director
of Estates and Facilities and the Fire Manager.
Fire Safety Policy Page 14 of 32
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Element to be Lead Tool Frequency Reporting arrangements Who or what
monitored committee will the completed report go to.
Roles and Fire Advisor Fire Risk Assessment Annual – Inpatient Areas Risk Assessment issued to Responsible
Responsibilities Every 2 years – Person(s) upon completion listing significant
Outpatient Areas findings
Every 3 years –
Administration Areas
Roles and Fire Assurance Audit As Required Estates and Facilities SMT
Responsibilities Manager
Roles and Fire Advisor UwFS / Fire Investigation As Required Executive Meetings – as required
Responsibilities UHL HS Committee – quarterly
UHL Fire Safety Group - quarterly
Fire Risk Local Fire Risk Assessment As Required
Assessment Manager /
Significant Matron
Findings
Local Fire Safety Fire Warden Fire Warden Checks As defined by Fire Log Fire Safety Manager – verbal
arrangments Book Local Manager - verbal
Fire Log Books Fire Adviser Fire Risk Assessment Annual – Inpatient Areas
Every 2 years –
Outpatient Areas
Every 3 years –
Administration Areas
Training Needs Fire Fire Risk Assessment Quarterly UHL HS Committee – quarterly
Analysis Manager UwFS / Fire Investigation UHL Fire Safety Group - quarterly
Reference Fire Technical Indices 6 monthly UHL Fire Safety Group
Documentation Manager CFOA / HSE / Gov.uk
Fire Safety Policy Page 15 of 32
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8.1 The Trust recognises the diversity of the local community it serves. Our aim
therefore is to provide a safe environment free from discrimination and treat all
individuals fairly with dignity and appropriately according to their needs.
8.2 As part of its development, this policy and its impact on equality have been
reviewed and no detriment was identified.
9 SUPPORTING REFERENCES, EVIDENCE BASE AND RELATED POLICIES
9.1 The Regulatory Reform (Fire Safety) Order 2005
9.2 The Health and Safety at Work etc. Act 1974
9.3 Construction (Design and Management) Regulations 2015
9.4 The Equality Act 2010
9.5 Healthcare Technical Memoranda (Fire code)
a) HTM 05-01: Managing Healthcare Fire Safety
b) HTM 05-02: Guidance to support functional provisions in Healthcare
c) HTM 05-03: Part A General Fire Safety
d) HTM 05-03: Part B Fire Detection and Alarm Systems
e) HTM 05-03: Part C Textiles and Furnishings
f) HTM 05-03: Part D Commercial Enterprise on Healthcare Premises
g) HTM 05-03: Part E Escape Lifts in Healthcare Premises
h) HTM 05-03: Part F Arson Prevention in NHS Premises
i) HTM 05-03: Part G Laboratories on Healthcare Premises
j) HTM 05-03: Part H Reducing Unwanted Fire Signals in Healthcare
k) HTM 05-03: Part J Fire Engineering in Healthcare Premises
l) HTM 05-03: Part K Fire Risk Assessment in Complex Healthcare
Premises
9.6 CLG Guidance: Fire safety risk assessment: healthcare premises
9.7 CLG Guidance: Fire safety risk assessment: sleeping accommodation
9.8 CLG Guidance: Fire safety risk assessment: offices and shops
9.9 Building Regs: Approved Document B (Fire Safety)
9.10 Building Regs: Approved Document M (Access to and use of buildings)
9.11 BS9999: Fire safety in the design, management and use of buildings
Fire Safety Policy Page 16 of 32
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10.1 The updated version of the Policy will be uploaded and available through INsite
Documents and the on the Trust’s externally-accessible Freedom of Information
publication scheme. It will be archived through the Trusts PAGL system
10.2 It should be noted that paper copies may not be the latest up-to-date version.
10.3 This policy and associated documentation will be reviewed every 3 years or
sooner as deemed necessary due to changes in Legislation, Healthcare
guidance, local practice, responsibilities or arrangements.
10.4 Review will be conducted by the Trust Fire Safety Manager and members of the
Fire Safety Group (committee) and approved by the Trust H&S Committee
Fire Safety Policy Page 17 of 32
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NB: Paper copies of this document may not be most recent version. The definitive version is held in the policy and guideline library on INsiteAppendix A – UHL Fire Safety Structure
Fire Safety Statutory and HTM
Requirement
Management Structure
Trust
Board
Chief
Executive
Director of Estates Trust
& Facilities Directors
Head of Estates Head of Capital CMG Heads
& Property
Estates Head of QSHE Project CMG Duty
Managers Compliance Managers Managers Managers
Estates Fire Safety Contractors
Staff Advisors (Projects)
ALL
Staff
Contractors
(PPM)
FIRE WARDENS
(and Deputies)
Fire Response
Fire System Team
Specialist
Authorising
Engineer (Fire) Key
Line of Management
External Communictions
Training and Support
Fire Safety Policy Page 18 of 32
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Description Role(s) Duration Frequency Tutor
Corporate Induction ALL Staff 45 min Upon commencement Fire Safety Officer
with the Trust
Local Induction ALL Staff Variable Upon commencement in Ward/Department
work area(s) Manager and/or Fire
Warden
Fire Safety Refresher ALL staff 60 min Annually Fire Safety Officer
(classroom) Non-patient contact admin staff Every 2 years
Fire Safety Refresher (e- Non-patient contact admin staff 30 min Every 2 years E-learning Module
learning)
Fire Evacuation Table Top Inpatient / Bedded areas 45 – 60 As required (not to Fire Safety Officer
mins exceed 24months)
Fire Evacuation Drill Outpatient / Admin areas 15 min Period not to exceed 24 Fire Safety Officer /
months Fire Wardens
Fire Warden Nominated Staff 180 min Refresh as required Fire Officer
Fire Response Team Duty Managers / Logistics / 60 min Annual Fire Officer
Security / Estates staff
Fire Safety Policy Page 19 of 32
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Site:
Building:
Department:
Assembly Point(s)
IT IS THE RESPONSIBILITY OF THE PERSON IN CHARGE OF THE DEPARTMENT TO ENSURE
THAT THE FIRE/EVACUATION ASSEMBLY POINTS ARE CABABLE OF SUPPORTING THE
CLINICAL NEEDS OF THEIR PATIENTS TO ENABLE CONTINUITY OF CARE
DISCOVERING A FIRE:
Sound the ALARM – Operate the nearest Manual Call Point (MCP)
Move those in immediate danger to a place of safety
Dial 2222 – Confirm FIRE and specify exact LOCATION
Tackle Fire if trained and safe to do so
Evacuate – move to the designated Assembly Point – await further instruction
Close doors as you evacuate the Ward / Department / Area
Take head count – Patients / Visitors / Staff etc.
Communicate with / await instructions from Duty Manage / Senior Person in Charge
CONTINUOUS ALARM SOUNDING:
Check the Fire Alarm “mimic” or “repeater” panel to establish location of activation.
Nominated Staff to investigate and establish if activation is genuine or false alarm.
Where no “mimic” or “repeater” panel is fitted / available a full visual Inspection (sweep)
of the department is required by nominated staff.
Search for signs of FIRE – Heat / Smoke / Flames
Search for signs of FALSE ALARMS – Burnt Food (toast) / Deodorant / Broken glass in
Manual Call Point(MCP), Continuous Light showing on MCP or Detectors
Once investigation is complete call 2222 to confirm FIRE or FALSE ALARM
Tackle Fire if trained and safe to do so
If Fire confirmed evacuate ALL occupants to the nominated Assembly Point(s)
Close doors as you evacuate the Ward / Department / Area
Take head count – Patients / Visitors / Staff etc.
Communicate with / await instructions from Duty Manage / Senior Person in Charge
INTERMITTENT ALARM SOUNDING:
Check the Fire Alarm “mimic” or “repeater” panel to establish location of activation.
Nominated Staff to investigate and establish if activation is genuine or false alarm.
If genuine nominated staff to assist with the evacuation of the effected ward/area
Conduct roll call and remain in ward – reassure patients / staff / visitors.
Prepare to move patients and receive possible evacuees from adjoining wards.
Follow instruction given by the Incident Commander / Senior Person in Charge
If advised to Evacuate to the nominated Assemble Point(s)
Fire Safety Policy Page 20 of 32
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INsiteACTIONS TO TAKE DURING EVACUATION:
The person in charge of the Department, the fire warden or a designated person must:
Ensure that ALL Confirmed incidents are reported to the Hospital Switchboard on 2222.
Ensure that staff do not endanger themselves or take any unnecessary risks in the process of vacating the
Department.
Supervise the evacuation of the Department - where possible and safe to do so close all doors and windows as
rooms are vacated
Ensure that those evacuated are evacuated to areas where their clinical needs can continue to be supported
Ensure that all patients and members of staff are evacuated and that the Department is secured (doors closed
fully).
Ensure that any patient visitors are evacuated with the patient to the designated Fire Assembly Point.
Ensure that any staff/patients in waiting areas are vacated.
Ensure that a nominal roll call is taken at the fire assembly point once all patients, staff and visitors have been
evacuated.
Establish where possible the whereabouts of staff members working outside the Department.
Wait in a safe location outside the front of the Department for the Duty Manager.
Inform the Duty Manager of the location of the fire if known.
Notify the Duty Manager or Senior Local Authority Fire Officer immediately of any member of staff or visitor
being unaccounted for.
Direct staff and any other persons requested to attend and assist in the evacuation (Porters and other Ward
staff)
HAZARD LOCATION AND FIRE EQUIPMENT:
COSHH store(s):
Gas Cylinder store(s)
Medical Gas Isolation
Fire Alarm Panel
STAFF LEVELS:
Between the hours of and there are staff on duty (dayshift)
Between the hours of and there are staff on duty (nightshift)
Between the hours of and there are staff on duty (weekends / other variations)
To implement this Evacuation Plan trained staff are required on Duty.
Name: Signature:
Date Competed: Review Date
IT IS THE RESPONSIBILITY OF THE PERSON IN CHARGE OF THE DEPARTMENT TO ENSURE
THAT THIS DOCUMENT REFLECTS AGREED LOCAL FIRE EVACUATION PROCEDUES.
If variations to normal activities are not covered then amendment must be made to reflect.
e.g. staffing levels (annual leave, sickness), specific patient requirements, lone working etc.
A separate plan may even be considered for such variations.
Fire Safety Policy Page 21 of 32
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INsiteAPPENDIX D - Personal Emergency Evacuation Plan Assessment
To be completed by the Line Manager with the assistance of the person for whom the PEEP is
intended (NB: may be a need to develop more than one plan if user occupies / attends more than one
building / site etc.)
Name: Assignment No.
Job Title:
Building: Department:
Floor: Manager:
(print name)
Date of Assessment :Manager:
(signature)
PEEP Questionnaire (answer Yes or No as applicable) Yes No
Section A – Auditory
Does the individual have an auditory impairment? (If not go to Section B)
Can the fire alarm be heard in normal circumstances?
Is a visual alarm indicator present in the workplace?
Is your response to the fire alarm aided by the support of others?
Do you work in isolation / times of low occupancy / in remote parts of the building etc.
Is there access to vibrating pagers in the workplace?
Section B – Visual
Does the individual have any visual impairment? (If not go to Section C)
Does the impairment impact on the individual’s ability to evacuate unassisted? (if not
go to Section C)
Does the individual currently use an aid to move around the workplace?
Please provide details:
How long would it take to leave the building unaided using the nearest available exit? ………min
Do you believe the time taken would have the potential to impact on other building
users evacuating via corridors and/or stairwells?
Could you safely exit the building by an alternative exit should the normal one be
unavailable?
Are there other issues you wish to highlight or solutions that may assist you?
If so please provide details below:
Section C - Mobility
Do you have mobility impairment? (if no, go to section D)
Are you able to leave the building unassisted? (if yes go to Section D)
Do you use / require a wheelchair?
Is the use of a wheelchair required at all times?
Is the wheelchair a standard size / weight? Enter details below
Width (mm) Weight (kg)……………………
Fire Safety Policy Page 22 of 32
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INsiteIs the wheelchair powered?
Are you able to self-transfer to an evacuation aid if required?
Could the medical nature of your disability be aggravated by the use of such a device?
Has a member of staff (and a deputy) been assigned to assist you in an emergency?
Provide details below
Name: Extension
Are there other issues you wish to highlight or solutions that may assist you?
If so please provide details below:
Section D – General Information
Do you understand the concept of a Fire Refuge area?
Do you know where the nearest accessible refuge is located?
Might the measures needed for you to escape from the building in an emergency
adversely affect the safe escape of other occupants?
If yes, why/how?
Do you think that any special staff training is required to give you the assistance that
you would need in an emergency?
Do you know what the Emergency Evacuation procedures are in the Building(s) in
which you work or visit?
Do you require written Emergency Evacuation procedures?
Is the signage marking the emergency exists clear and legible?
Could you raise the alarm if you discovered a Fire?
Are there any other issues / concerns that you have in relation to your evacuation
plan?
If so provide details below:
Use the space below for any other notes believed to be pertinent to this assessment
Fire Safety Policy Page 23 of 32
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INsiteAPPENDIX E - Personal Emergency Evacuation Plan (PEEP)
Name: Assignment No.
Job Title:
Building(s): Department(s):
Floor(s): Manager:
(print name)
Date of Assessment Manager:
(signature)
Awareness of Procedure:
I have received a copy of information about the emergency evacuation procedures in: (tick)
Braille Sign Language Print Large Print
Disk Other – Specify
Alarm System:
I am informed of an Emergency by: (tick all that apply)
Existing Alarm Visual Alarm Pager Vibrating Alarm
Colleagues Other - Specify
Designated Assistance:
The following people have been designated to provide assistance when I need to evacuate the
building in an emergency.
Name: Contact Number:
Methods of Assistance
The following equipment is required / has been provided to aid evacuation
Evac Chair ResQmat Mechanical Hoist Vibrating Pager
None Required Other - Specify
The equipment listed above is required at the following locations
Confirmation of Use of Equipment
The use of the equipment I need has been explained to me Yes No
I require further training on the use of evacuation equipment Yes No
Evacuation Procedure:
Fire Safety Policy Page 24 of 32
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INsiteThese are the step by step instruction beginning from the sounding of the first alarm
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Attached a Plan if appropriate
Confirmation of Receipt and use of PEEP
I understand that I am responsible for keeping my PEEP as accurate as possible and alerting any
change in circumstances to my line manager as soon as possible to ensure a prompt review
The data provided on this form and on the questionnaire will only be available to UHL staff, who may
require the information for the purpose of safeguarding your health, safety and wellbeing whilst you
are at work. It may also be shared with the Emergency services if necessary.
It will be stored in accordance with the Information Governance Policy and DPA
I understand the above notice and give consent for my data to be shared as detailed above.
Signature of Staff Member: Signature of Line Manager:
Date: Date:
Fire Safety Policy Page 25 of 32
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INsiteAppendix F – Fire / Unwanted Fire Signal Report
INCIDENT TYPE: FIRE: UNWANTED FIRE SIGNAL
(PAGE 1 TO BE COMPLETED FOR ALL ALARM ACTIVATIONS)
SITE: Choose an item. DATE : Click here to enter a date.
SUMMARY OF EVENTS: TIME: (24HR)
Use the space below to summarise events leading up to the alarm activation as subsequent actions
ALARM SIGNAL DETAILS: FIRE RESPONSE DETAILS:
LOCATION: (Use drop down boxes to select) FIRE SERVICE ATTENDANCE:
TABLE 1 LIST1 – PREMESIS TYPE TIME OF CALL TO FIRE SERVICE :(24HR)
Choose an item. TIME OF FIRE SERVICE ARRIVAL :(24HR)
TABLE1 LIST2 – AFFECTED PARTS FIRE RESPONSE TEAM ATTENDANCE:
Choose an item. DUTY MANAGER YES NO
TABLE 2 - AREA TYPES SECURITY YES NO
Choose an item. LOGISITICS YES NO
TABLE 3 – ROOMS ENGINEER YES NO
Choose an item.
FIRE CAUSATION CLASSIFICATION: FIRE SERVICE CLASSIFICATION
(IF DIFFERENT FROM INITIAL)
Choose an item. Choose an item.
IF OTHER IS SELECTED PLEASE PROVIDE ADDITIONAL INFORMATION:
EXTENT OF EVACUATION
UNNECCESSARY DEPARTMENT FLOOR ADJACENT BUILDING(S)
ROOM ONLY STREET CORRIDOR OTHER FLOOR(S) OTHER (SPECIFY BELOW)
WHOLE BUILDING ADJACENT ROOM(S) ADJACENT DEPARTMENT
PERSONS INVOLVED:
NO OF PEOPLE IN ROOM OF ORIGIN: PATIENTS STAFF VISITORS
NO OF PEOPLE EVACUATED FROM ROOM: PATIENTS STAFF VISITORS
NO OF PEOPLE EVACUATED FROM DEPT: PATIENTS STAFF VISITORS
NO OF PEOPLE EVACUATED FROM FLOOR: PATIENTS STAFF VISITORS
Fire Safety Policy Page 26 of 32
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INsiteTO BE COMPLETED FOLLOWING ANY FIRE:
FIRE DISCOVERED BY:
EMPLOYEE VISITOR PASSER BY PATIENT
SMOKE DETECTOR HEAT DETECTOR SPRINKLER OTHER (SPECIFY BELOW)
METHOD OF EXTINGUISHMENT:
NONE FIRE HOSE SMOTHERING CO2 / POWDER ETC
SELF EXTINGUISHED WATER REMOVAL FIRE SERVICE
EXTINGUISHER EQUIPMENT ISOLATION SPRINKLER OTHER (SPECIFY BELOW)
MATERIALS FIRST INGITED:
RAW MATERIALS BEDDING/MATTRESS FITTINGS DECORATION/SOFT TOYS
VEGETATION UPHOLSTERY FOOD CLEANING MATERIALS
CLOTHING OTHER FURNISHINGS ELEC INSULATION WASTE
OTHER TEXTILES STRUCTURE LAGGING UNKNOWN
OTHER (SPECIFY)
SPREAD OF FIRE WITHIN ROOM OF ORIGIN
NOT APPLICABLE STORED MATERIAL EQUIPMENT OTHER (SPECIFY BELOW)
CONFINED TO ITEM FURNISHING-LININGS FURNISHINGS-FITTINGS
CAUSE OF FIRE:
DELIBERATE WATER HEATING EQUIPMENT - ELEC SMOKING
COOKING APPLIANCES HOTWORKS EQUIPMENT - MECH UNKOWN
SPACE HEATING LIGHTING WIRE/CABLE - FIXED OTHER (SPECIFY BELOW)
CENTRAL HEATING NAKED LIGHTS WIRE/CABLE - LEADS
SPREAD OF SMOKE BEYOND ROOM OF ORIGIN:
NOT APPLICABLE ADJACENT ROOM(S) STAIRWAY(S) ADJACENT BUILDING(S)
CONFINED TO ITEM STREET CORRIDOR OTHER FLOOR(S) OTHER (SPECIFY BELOW)
CORRIDOR(S) ADJACENT DEPT ROOF VOID(S)
SPREAD OF BURNING BEYOND ROOM OF ORIGIN:
NOT APPLICABLE ADJACENT ROOM(S) STAIRWAY(S) ADJACENT BUILDING(S)
CONFINED TO ITEM STREET CORRIDOR OTHER FLOOR(S) OTHER (SPECIFY BELOW)
CORRIDOR(S) ADJACENT DEPT ROOF VOID(S)
ROUTE OF FIRE SPREAD:
NOT APPLICABLE SPACES/VOIDS OPEN FIRE DOORS EXTERNAL
DUCTS FIRE STOPPING STAIRS/LIFTS OTHER (SPECIFY BELOW)
INJURY FIGURES (WHERE APPLICABLE) ENTER NUMBERS
INJURY CAUSED BY BURNS: PATIENTS STAFF VISITORS
INJURY CAUSED BY SMOKE INHALATION: PATIENTS STAFF VISITORS
INJURY CAUSED BY EVACUATION: PATIENTS STAFF VISITORS
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